Training Manual for Community Health Workers

WINGS
WOMEN IN
INDIA with GDM
STRATEGY
An International Diabetes Federation Project
The content in this brochure has been developed by the International Diabetes
Federation (IDF) in collaboration with the Madras Diabetes Research Foundation
(MDRF) in Chennai, India, based on the learnings from the WINGS Project (Women in
India with GDM Strategy). The WINGS project was developed and supported through a
partnership among IDF, MDRF and the Abbott Fund, the philanthropic foundation of the
global healthcare company Abbott.

Advisory Board
Ms. Anne Belton, Chair
Dr. V. Mohan, Principal Investigator
Ms. S. Mahalakshmi
Dr. Ranjit Unnikrishnan
Dr. R.M. Anjana
Ms. Rutu Dave
Dr. Uma Ram
Dr. Usha Sriram
Dr. Sonak D. Pastakia, Consultant, AMPATH Kenya

IDF
Dr. Belma Malanda
Dr. A Kayal
TABLE OF CONTENTS

What is gestational diabetes mellitus (GDM)? 4

Why should we treat women with gestational diabetes? 5
Who should be screened and how? 6
Why is self-management education important? 8
Nutrition 9
Exercise 12
Monitoring 13
Pharmacological Management 14
Hypoglycemia (low blood sugar) 15
After the baby is born 17
Future pregnancies 18
Notes 19

Training Manual for Community Health Workers 3

WHAT IS GESTATIONAL
DIABETES MELLITUS
(GDM)?
When a pregnant woman who is not known to have diabetes before becoming pregnant has
blood sugar levels above a certain level, she is diagnosed as having gestational diabetes.
This usually occurs between 24 and 28 weeks of the pregnancy, but may show up earlier
or later.

The pregnancy hormones work against insulin so pregnant women need more insulin
than usual. Most women are able to produce more insulin during their pregnancy. Some
women cannot produce more usually due to being overweight, having a family history
of diabetes or being older. These women may develop gestational diabetes.

Gestational diabetes is very common, some studies have shown 1020% of women will
have it. It is more common in women who are overweight, older, less active or have a
family history of diabetes.

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WHY SHOULD WE
TREAT WOMEN
WITH GESTATIONAL
DIABETES?
If not treated gestational diabetes may result in problems for both
mother and baby.

COMPLICATIONS FOR THE MOTHER

She may develop high blood pressure
She may have to have a caesarean section
She may go into labour early
She may develop type 2 diabetes within 5 10 years
She has a higher risk of developing cardiovascular disease in
the future

COMPLICATIONS FOR THE BABY

The baby may get too big
The babys blood sugar level may drop too low after birth
The baby may have jaundice
The baby may be injured during vaginal delivery, due to being
too big
The baby may have trouble breathing
The risk of being overweight as a child is higher
The risk of developing type 2 diabetes in the future is higher

Training Manual for Community Health Workers 5

WHO SHOULD BE
SCREENED FOR
GESTATIONAL
DIABETES AND HOW?
All pregnant women should be screened at the rst visit to the antenatal clinic. Early in
pregnancy screening is done to see if the woman already has diabetes that she does not
know about. Screening can be done using a fasting plasma glucose (FPG), glycosylated
haemoglobin (A1C) or a random plasma glucose (RPG). If one of the results is higher
than the numbers below, the woman should be treated as having diabetes before she
became pregnant.

FPG > 7 mmol/L (126 mg/dl)

A1C > 6.5%
RPG > 11.1 mmol/L (200 mg/dl)

All women who have normal levels on these tests early in pregnancy should be screened
again between 24 and 28 weeks of the pregnancy. At this time the woman should come
to the clinic fasting, that is nothing to eat or drink, except water, for at least 8 hours.
She will have some blood drawn then be given a glucose drink, after which blood will be
drawn in one and two hours. If one of the tests is high the woman will be diagnosed with
gestational diabetes (see box on the next page for the diagnostic levels).

If possible all blood tests should be done using venous blood and sent to a lab, not
measured using a handheld glucose meter.

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SCREENING FOR GDM AT 24 - 28 WEEKS

COME TO CLINIC FASTING

DRAW BLOOD SAMPLE

DRINK SPECIAL GLUCOSE DRINK

BLOOD TAKEN AT 1 HOUR

BLOOD TAKEN AT 2 HOURS

IF RESULT:

Fasting 5.1 6.9 mmol/L (92-125 mg/dl)

Or
1 hour 10 mmol/L (180 mg/dl)
Or
2 hour 8.5 mmol/L (153 mg/dl)

GESTATIONAL DIABETES

Women who have normal results but are at high risk of gestational diabetes should be
retested at 32 weeks.

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WHY IS SELF-
MANAGEMENT
EDUCATION
IMPORTANT?
Women want to be healthy and have healthy babies. They are responsible for their own
care 24 hours a day. They need to know what they can do to have a healthy pregnancy
and a healthy baby.

The situation and needs of each woman need to be considered when treatment is planned.
Suggestions for a healthy pregnancy need to be tailored to what the woman is able to do
and what she is willing to do. This means considering her living situation, support from
family, nances and ability to make the recommended changes.

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NUTRITION
One of the key factors in managing gestational diabetes is healthy eating. When possible
all pregnant women should see a dietitian who will prepare an appropriate meal plan.

Women should be advised to eat 3 meals and 3 snacks during the day. Spreading the food
out over the day helps to keep the blood sugars balanced.

To get all the nutrients, minerals and vitamins needed for a healthy pregnancy and baby,
women should eat foods from a variety of sources.
Grains and starches, such as wheat, brown rice
Vegetables and fruit
Vegetable protein such as lentils, pulses, tofu and nuts
Animal proteins such as egg whites, chicken and sh
Milk and milk sources such as yogurt, cheese
Note:
Fish that may contain higher levels of methyl mercury should be limited such as
fresh and frozen tuna, shark, swordsh, marlin, orangy roughy and escolar

Some general guidelines for healthy eating:

Include 4-5 servings of yellow and green vegetables in the daily diet
Include iron rich foods such as brown rice , wheat germ
Include fresh wholesome foods whole fruits instead of juices, whole grains/
multigrain ours instead of rened ours
Include adequate intake of uids 2 litres/day unless advised a lower amount
Include a minimum of 650 ml milk or alternate to meet calcium needs
Eat less junk foods, bakery products, fried foods, salted foods
Use less oil in cooking
Avoid direct sugars, saccharin and cyclamates
Minimize the use of other articial sweeteners
Avoid alcohol and tobacco and recreational or non prescription drugs in all forms.

Training Manual for Community Health Workers 9

A simple way to teach healthy eating is to suggest that the plate be half covered with
vegetables and fruits, covered with grains and starches and covered with protein.

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All pregnant women should gain some weight during pregnancy. The amount of weight
to gain depends on the weight before becoming pregnant.

If the BMI is Recommended weight gain is

Less than 18.5 12.5 18 kg

18.5 - 24.9 11.5 - 16 kg

25 - 29.9 7 - 11.5 kg

Over 30 5 - 9 kg

Weight in kg
= BMI
Height in meters2

AN EXAMPLE:
Weight is 65 kg
Height is 1.6 meters

65
= 23.3 = BMI
1.6 x 1.6

Most women should add about 350 calories to their daily intake around the 4th month. For
those who are overweight fewer calories should be added, for those who are underweight
more calories could be added. Where possible a dietitian should recommend the amount
of calories to add.

Training Manual for Community Health Workers 11

EXERCISE
Any physical activity is better than no physical activity during pregnancy.
Even low levels of physical activity have shown benet in control of blood sugars.
Aerobic activity of moderate intensity for 30 minutes a day on most days of the
week is the usual recommendation to help control blood sugars. Aerobic activity
is walking, biking or swimming.
Upper body resistance training in addition to the aerobic activity may help in
controlling blood sugars.

SOME CAUTIONS ABOUT EXERCISE

Exercise should not be done while lying at on the back.
Exercise should be stopped if contractions are felt.
Exercise should be stopped if the heart rate goes over 140 beats per minute.
If the woman is taking insulin and has symptoms of a low blood sugar, exercise
must be stopped and the low sugar treated.

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MONITORING

BLOOD SUGAR
Women will have their blood sugar checked every time they go to the clinic or health centre.

Target levels during pregnancy are:

Fasting or before eating or drinking anything: less than 5.3 mmol/L (90 mg/dl)
1 hour after eating a meal: less than 7.8 mmol/L (140 mg/dl)
2 hours after eating a meal: less than 6.7 mmol/L (120 mg/dl)
Some women will test at home using a blood glucose meter. If they are testing at home
they could test before breakfast and at 1 or 2 hours after one or more meals a couple of
days a week. If the results are higher than the target levels the doctor should be notied.

ULTRASOUND
Most women will have an ultrasound done several times during the pregnancy. These are
done to determine the size of the baby and to make sure the baby is developing normally.

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PHARMACOLOGICAL
MANAGEMENT
INSULIN
When blood sugars continue to be above the target levels in spite of a healthy meal plan
and regular activity, the best way to get them down is to start insulin. Insulin must be
injected daily, sometimes several times a day, depending on the type of insulin prescribed.
The doctor will prescribe the insulin dose.

Things to remember about insulin

Insulin must be kept between 15 and 30 degrees Celsius. It can be kept out of
the fridge if the room does not get hotter than 30 degrees, otherwise it should
be kept in the fridge, but not in the freezer.
If insulin is kept in the fridge it should be allowed to warm slightly before it is
injected. This is done by letting it sit in the room for a few minutes. Do not put
it in warm water to warm it.
Insulin must never be allowed to freeze.
Insulin should be stored away from a source of heat.
If no refrigeration is available it could be stored on a clay pot lled with water.
Insulin may be damaged by direct sunlight or vigorous shaking. Cloudy insulin
(N, NPH or premixed insulins) need to be rolled between two hands (not shaken)
to mix it before it is used.

The most common side effect of insulin is low blood sugar, meaning the insulin worked
too well and the level dropped below 4 mmol/L (72 mg/dl). See next page for more about
low blood sugars.

Some women may be prescribed metformin (a pill) instead of insulin. Metformin has
been shown to be safe for use in pregnancy but insulin is still considered the best choice.

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HYPOGLYCEMIA OR
LOW BLOOD SUGAR
ONLY THOSE TAKING INSULIN ARE AT RISK OF
A LOW BLOOD SUGAR.
Blood sugars drop too low when:
The woman has not eaten enough carbohydrate (grains, starches, fruit)
The meal is late or missed
The woman has done a lot of activity but not eaten enough
The woman took too much insulin for the planned meal
Signs of hypoglycemia
Shaking
Heart pounding
Sweating
Hunger
Tiredness, no energy
Headache
Mood change
Confusion
Agitation
Passing out

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Treatment of low blood sugar
A low blood sugar must be treated immediately - if not treated the woman may have a
seizure and pass out.

If possible check the blood sugar level with a glucose meter.

Give the woman 15 grams of sugar, this could be:

3/4 cup of fruit juice
3/4 can of regular (not lite, zero or diet) soft drink
4-6 hard candies, to be chewed
3 teaspoons of sugar or honey
If there is no improvement in 10 - 15 minutes, give the same amount of sugar again.

If the low blood sugar happens before a meal, it should be treated and then the meal
eaten as usual.

If the next meal is more than 1 hour away, a snack should be taken. The snack should
be a starch and some protein.

If low blood sugars happen frequently (more than one time a week) the doctor should be
consulted and the insulin dose may need to be changed.

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AFTER THE BABY
IS BORN
All women should be encouraged to breastfeed.

Women will have their blood sugars tested after delivery - in gestational diabetes blood
sugars return to normal after delivery and insulin will no longer be needed. Some women
will not return to normal blood sugar levels after the baby is born. They will need guidance
regarding healthy eating and medications to keep their blood sugars in the normal range.

The risk of developing diabetes in the future is high, therefore women should be encouraged
to eat a healthy meal plan and achieve a healthy body weight.

All women need to have their blood glucose tested between 6 - 12 weeks after the baby
is born. This test will require the woman to go to the clinic or centre before she has eaten
anything in the morning. Blood will be drawn, then she will be given a sugary drink and
blood will be drawn again after 2 hours.

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FUTURE
PREGNANCIES
Women should plan when they will become pregnant again. They should be educated on
birth control methods to ensure they do not become pregnant before they want to and
only when the woman is ready and in optimal health.

Women should be encouraged to achieve a healthy weight prior to becoming pregnant

again as this may lessen the chance of developing gestational diabetes a second time.

Prior to becoming pregnant, blood glucose levels should be checked and there should
be a consultation with a doctor to make sure the woman has not developed diabetes in
the interim.

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NOTES

Training Manual for Community Health Workers 19

 WINGS
WOMEN IN
INDIA with GDM
STRATEGY
An International Diabetes Federation Project